The Oregon Practitioner Recredentialing Application serves as a comprehensive form used by healthcare providers to maintain their credentials within the state's hospitals and health plans. Established through Oregon House Bill 2144 in 1999, it is meticulously designed to facilitate the uniform recredentialing process, as endorsed by the Advisory Committee on Physician Credentialing Information (ACPCI). Applicants are required to provide detailed professional information, including any actions related to professional liability, to ensure their qualifications and history are transparent and current.
Navigating the requirements for maintaining and updating practitioner credentials in Oregon has been streamlined by the Oregon Practitioner Recredentialing Application, a comprehensive form developed in alignment with House Bill 2144 from 1999. This initiative, supported by the Advisory Committee on Physician Credentialing Information (ACPCI), acknowledges the need for a uniform process for hospitals and health plans to credential and recredential practitioners across the state. Applicants are advised to fill out the form with meticulous attention to detail, ensuring that all information presented is current, complete, and accurate, with required documentation including state professional licenses and DEA certificates among others clearly attached. The form intricately covers a wide array of necessary information, from basic personal and contact details to more specific professional and educational backgrounds, including board certifications and continuous medical education achievements. Additionally, it emphasizes the importance of attaching a detailed Attestation Questions page and an Authorization and Release of Information Form, alongside the Professional Liability Action Detail if relevant. Attention to additional instructions indicating the form should be typed or legibly printed, and the protocol for non-applicable sections, are critical aspects emphasized for successful submission. Through this detailed application, the state ensures a thorough and standardized process for recredentialing practitioners, aiming to uphold the highest standards of healthcare provision within Oregon.
OREGON PRACTITIONER RECREDENTIALING
APPLICATION
APPLICATION
PROFESSIONAL LIABILITY ACTION DETAIL (ATTACHMENT A)
GLOSSARY OF TERMS AND ACRONYMS
Purpose: Established by 2UHJRQhouse bill 2144 (1999), the $ dvisory &ommittee on 3hysician &redentialing,nformation (ACPCI) develops the uniform applications used by hospitals and
health plans to credential and recredential PRACTITIONERS within the State of 2regon.
REVIEWED, AMENDED AND APPROVED
BY THE ADVISORY COMMITTEE ON PHYSICIAN CREDENTIALING INFORMATION (ACPCI)
5/1/12
Oregon Practitioner Recredentialing Application
Prior to completing this recredentialing application, please read and observe the following:
I.
INSTRUCTIONS
This form should be typed (using a different font than the form) or legibly printed in black or blue ink. If more space is needed than provided on original, attach additional sheets and reference the question being answered.
Modification to the wording or format of the Oregon Practitioner Recredentialing Application will invalidate the application.
Complete the application in its entirety. Keep an unsigned and undated copy of the application on file for future requests. When a request is placed, send a copy of the completed application to the health care related organization to which you are applying, making sure that all information is complete, current and accurate.
Please sign and date page 8, Attestation Questions and page 9, Authorization and Release of Information Form (and Attachment A, Professional Liability Action Detail, if applicable).
Each page of the application requires the applicant’s initials and the date on which the application was last reviewed.
Identify the health care related organization(s) to which this application is being submitted in the space provided below.
Attach copies of the documents requested each time the application is submitted.
If a section does not apply to you, please check the provided box at the top of the section.
Mail application to the requesting organization(s).
Current copies of the following documents must be submitted with this application:
State Professional License(s)
DEA Certificate or CSR Certificate
ECFMG (if applicable)
Face Sheet of Professional Liability Policy or Certificate
A curriculum vitae is optional and not an acceptable substitute.
I am applying to (please list: Hospital Staff, HMO, IPA):
for
(i.e., staff membership, network participation,
if applicable).
*Note: Please return completed application to the health care related organization to which you are applying, not to the State of Oregon.
Oregon Practitioner Recredentialing Application 5/1/12
Page 1 of 10
INITIALS:
DATE:
OREGON PRACTITIONER RECREDENTIALING APPLICATION
II.
PRACTITIONER INFORMATION
Please provide the practitioner’s full legal name.
Last name (include suffix; Jr., Sr., III):
First:
Middle:
Degree(s):
Is there any other name under which you have been known or have used since starting professional training?
Yes
No
Name(s) and year(s) used:
Home street address:
Home telephone number:
Mobile/alternate number:
(
)
Email address:
City:
State:
ZIP:
Country:
Birth date (month/day/year):
Birth place:
/
Citizenship:
Social Security number:
Gender:
Male
Female
Immigrant visa number (if applicable):
Visa expiration date:
Type:
III.SPECIALTY INFORMATION
This information may be included in directory listings.
Principal clinical specialty (For most current specialties list, see:
Do you want to be designated as a primary care practitioner (PCP)?
http://www.wpc-edi.com/codes):
Additional clinical practice specialties:
Category of professional activity, check all boxes that apply:
Clinical practice:
Other professional activities:
Full time
Part time
Administration
Teaching
Locum/temporary
Telemedicine
Research
Retired
Other (explain):
IV. BOARD CERTIFICATION/RECERTIFICATION
Does not apply
This section does not apply to licensure.
List all current and past certifications. Please attach additional sheets, if necessary.
Date
Expiration date
Name and address of issuing board:
Specialty:
certified/recertified
(if any)
month/year:
If not currently board certified, describe your intent for certification, if any, and dates of previous testing and/or intended future testing for certification below. Please attach additional sheets, if necessary.
Page 2 of 10
INITIALS: ____________DATE: _____________________________
V.
OTHER CERTIFICATIONS
Please attach copy of certificate(s), if applicable.
Examples include: ACLS, BLS, ATLS, PALS, NRP, AANA, Fluoroscopy, Radiography, etc.
Number:
Month/year of certification:
Month/year of expiration:
For additional certifications, please attach a separate sheet.
VI.
PRACTICE INFORMATION
Name of primary practice/affiliation or clinic:
Department name (if hospital based):
Primary clinical practice street address:
Effective date at location, month/year:
County:
Primary office telephone number:
Primary office fax number:
Patient appointment telephone number:
Ext.:
Mailing/billing address (if different from above):
Attn:
Office manager:
Office manager’s telephone number:
Office manager’s fax number:
Exchange/answering service number:
Pager number:
Office email address:
Recredentialing contact and address (if different
from above):
Recredentialing contact’s telephone number:
Recredentialing contact’s fax number:
Recredentialing contact’s email address:
Federal tax ID number or Social Security number, if
used for
Name affiliated with tax
ID number:
business purposes:
Secondary clinical practice street address:
Secondary office telephone number:
Secondary office fax number:
Federal tax ID number or Social Security number,
if used for
Please list other office locations with above information on a separate sheet.
Page 3 of 10
VII.
PRACTICE CALL COVERAGE
Please provide the name and specialty of those practitioners who
provide care for your patients when you are unavailable.
NAME:
SPECIALTY:
1.
2.
3.
4.
5.
VIII.
ADDITIONAL EDUCATION
If you have completed additional residencies,
internships or advanced specialized education within the past three (3) years, please provide the
following information. Please attach additional sheets, if necessary.
Complete name and street address of program:
Phone number:
Fax
number, if available:
From month/year:
To month/year:
Month/year of completion:
Did you complete the program?
(If you did not complete the program, please explain on a separate sheet.)
IX. CONTINUING MEDICAL EDUCATION Please list activities for which
you have received CME credit(s) during the past two (2) years. Please attach a separate sheet, if needed.
Name:
Month/year attended:
Hours:
X.HEALTH CARE LICENSURE, REGISTRATIONS, CERTIFICATES AND
ID NUMBERS Please attach additional sheets, if necessary.
Oregon license or registration number:
Month/day/year of expiration date:
Drug Enforcement Administration (DEA) registration
number (if applicable):
Controlled substance registration (CSR) number (if applicable):
Month/day/year issued:
Individual NPI number:
Medicare number:
DMAP number:
Page 4 of 10
XI. OTHER STATE HEALTH CARE LICENSES, REGISTRATIONS
AND CERTIFICATES Please attach additional sheets, if necessary
State/country:
Year obtained:
Month/day/year of expiration:
Year relinquished:
Reason:
XII. HOSPITAL AND OTHER HEALTH CARE FACILITY AFFILIATIONS
Please list for the past three (3) years all health care institutions where you have and/or have had clinical privileges and/or staff membership. Include all (A) affiliations in the past three (3) years, and/or (B) applications in process (i.e., hospitals, surgery centers or any other health care related facility). If more space is needed, please attach additional sheets. Do not list residencies, internships or fellowships. Please list employment in Section XIII, Professional Practice/Work History.
A. AFFILIATIONS IN THE PAST THREE (3) YEARS
Facility name:
Fax number, if available:
Complete address:
Status (e.g. active, courtesy, provisional, allied
Month/day/year of appointment:
health, etc.):
Status:
If you do not have hospital admitting privileges, check here:
Please explain on a separate sheet your plan for continuity of care for your patients who require admitting.
B. APPLICATIONS IN PROCESS
Month/year of submission:
Month /year of submission:
Facility Name:
Page 5 of 10
XIII.
PROFESSIONAL PRACTICE/WORK HISTORY
A curriculum vitae is not sufficient.
A.
Please chronologically list and account for work, professional and practice history activities for the past three (3) years to
present, including military service. Please explain in section B any gaps greater than two (2) months.
Please attach additional sheets, if necessary.
Name of current practice/employer:
Contact’s name:
Telephone number:
Fax number:
Contact’s email address, if available:
Professional liability carrier:
Name of previous practice/employer:
From month / Year:
Page 6 of 10
B. Please explain any gaps greater than two (2) months in the past three (3) years. Include activities and/or names and dates where applicable. Please attach additional sheets,
if necessary.
Activities and/or names:
XIV. PEER REFERENCES
Please list three (3) references, from peers who through recent observations, are directly familiar with your clinical skills and current competence. Do not include relatives. If possible, include at least one member from the Medical Staff of each facility at which you have privileges.
Name of reference:
Complete address, include department if applicable:
Professional relationship:
Email address, if available:
Page 7 of 10
XV.
PROFESSIONAL LIABILITY INSURANCE
Current insurance carrier/provider of professional liability coverage:
Policy number:
Type of coverage (check one):
Claims-made
Occurrence
Name of local contact:
Mailing address:
Contact’s telephone number:
Per claim limit of liability:
Aggregate amount:
Month/day/year effective:
Month/day/year retroactive date,
if applicable:
Please list all previous professional liability carriers within the past three (3) years. Please attach additional sheets, if necessary.
Insurance carrier/provider of professional liability coverage:
Page 8 of 10
XVI.
ATTESTATION QUESTIONS – This section to be completed by the Practitioner.
Modification to the wording or format of these Attestation Questions will invalidate the application.
Please answer the following questions “yes” or “no”. If your answer to any of the following questions is “yes”, please provide details and reasons, as specified in each question, on a separate sheet. Please sign and date each additional sheet.
A.In the last three (3) years has your license, certification, or registration to practice your profession, Drug Enforcement Administration (DEA) registration, or narcotic registration/certificate in any jurisdiction ever been denied, limited,
suspended, revoked, not renewed, voluntarily or involuntarily relinquished, or subject to stipulated or probationary
YES
NO
conditions, had a corrective action, or have you ever been fined or received a letter of reprimand or is any such action
pending or under review?
B.In the last three (3) years have you ever been suspended, fined, disciplined, or otherwise sanctioned, restricted
or excluded for any reasons, by Medicare, Medicaid, or any public program or is any such action pending or
under review?
C.In the last three (3) years have you ever been denied clinical privileges, membership, or contractual participation by
any health care related organization*, or have clinical privileges, membership, participation or employment at any such
organization ever been placed on probation, suspended, restricted, revoked, voluntarily or involuntarily relinquished or
not renewed, or is any such action pending or under review?
D.In the last three (3) years have you ever surrendered clinical privileges, accepted restrictions on privileges,
terminated contractual participation or employment, taken a leave of absence, committed to retraining, or resigned
from any health care related organization* while under investigation or potential review?
E.In the last three (3) years has an application for clinical privileges, appointment, membership, employment or
participation in any health care related organization* ever been withdrawn on your request prior to the organization’s
final action?
F.In the last three (3) years has your membership or fellowship in any local, county, state, regional, national, or
international professional organization ever been revoked, denied, limited, voluntarily or involuntarily relinquished or
G.
In the past three (3) years, have you ever voluntarily or involuntarily left or been discharged from medical school or
subsequent training programs?
H.
In the last three (3) years have you ever had board certification revoked?
In the last three (3) years have you ever been the subject of any reports to a state or federal data bank or state
licensing or disciplinary entity?
J.
In the last three (3) years have you ever been charged with a criminal violation
r ?
(felony or misdemeano )
K.
Do you presently use any illegal drugs?
L.Do you now have, or have you had, any physical condition, mental health condition, or chemical dependency condition
(alcohol or other substance) that affects or is reasonably likely to affect your current ability to practice, with or without
reasonable accommodation, the privileges requested?
If reasonable accommodation is required, please specify the accommodation(s) required on a separate sheet.
M.Are you unable to perform any of the services/clinical privileges required by the applicable participating practitioner
agreement/hospital appointment, with or without reasonable accommodation, according to accepted standards of
professional performance?
N.In the last five (5) years have any professional liability claims or lawsuits ever been closed and/or filed against you?
If yes, please complete Attachment A, Professional Liability Action Detail, for each past or current claim
and/or lawsuit.
O.In the last three (3) years has your professional liability insurance ever been terminated, not renewed, restricted,
or modified (e.g. reduced limits, restricted coverage, surcharged), or have you ever been denied professional
liability insurance?
*e.g. hospital, medical staff, medical group, independent practice association (IPA), health plan, health maintenance organization (HMO), preferred provider organization (PPO), physician hospital organization (PHO), medical society, professional association, health care faculty position or other health delivery entity or system
I certify the information in this entire application is complete, current, correct, and not misleading. I understand and acknowledge that any misstatements in, or omissions from this application will constitute cause for denial of my application or summary dismissal or termination of my clinical privileges, membership or practitioner participation agreement. A photocopy of this application, including this attestation, the authorization and release and any or all attachments has the same force and effect as the original. I have reviewed this information on the most recent date indicated below and it continues to be true and complete. While this application is being processed, I agree to update the information originally provided in this application should there be any change in the information.
I agree to provide continuous care for my patients, until the practitioner/patient relationship has been properly terminated by either party, or in accordance with contract provisions.
Signature:
Date:
Page 9 of 10
Filling out the Oregon Practitioner Recredentialing Application is a critical step for healthcare professionals looking to maintain their credentials within the state. This form is often required by hospitals and health plans alike to ensure that practitioners meet the necessary standards for patient care. Completing this application accurately and thoroughly is essential for smooth processing. Follow these steps to ensure your application is submitted correctly.
Remember, keeping an unsigned and undated copy of the application on file can be beneficial for future requests. Paying close attention to detail and following these steps closely can help streamline the recredentialing process, ensuring you can focus more on delivering quality patient care.
To ensure the application is thorough and compliant, the following documents must be submitted:
It's important to note that a curriculum vitae is optional and cannot replace the requested documents.
The completed application, along with all required documentation, should be sent directly to the health care related organization you are applying to. It is critical not to send it to the State of Oregon but to the specific hospital staff, HMO, IPA, or other organizations where network participation or staff membership is sought.
If the space provided in the original document is insufficient:
This ensures all information is organized and easily understood by the reviewing committee.
For sections that do not apply to your situation, you must check the box provided at the top of the section to indicate it's not applicable. This helps clarify your circumstances and speeds up the review process by informing the committee of areas that do not concern your application.
Yes, the application process necessitates that each page of the Oregon Practitioner Recredentialing Application be initialed and dated. This requirement ensures that the information provided is verified and current as of the last review. Responsible completion of these details is crucial for the credibility and validity of your application.
Filling out the Oregon Practitioner Recredentialing Application form is a crucial step for healthcare practitioners in Oregon. While it may seem straightforward, a few common oversights can complicate the process. By paying close attention to the following points, applicants can ensure a smoother application process.
Not following specific instructions for filling out the form. The application must be typed or legibly printed in black or blue ink. Any modifications to the wording or format can invalidate the application.
Omitting signatures and dates where required. It is essential to sign and date page 8 (Attestation Questions) and page 9 (Authorization and Release of Information Form, including Attachment A if applicable). Every page also requires the applicant's initials and the last review date.
Failing to include necessary documents. Applicants must attach current copies of their State Professional License(s), DEA or CSR Certificate, ECFMG (if applicable), and the Face Sheet of their Professional Liability Policy or Certificate. A curriculum vitae, though optional, cannot replace these documents.
Skipping sections that do not apply without marking them appropriately. If a section is not relevant, you must check the provided box at the top of that section to acknowledge its non-applicability.
Not providing complete and current information throughout the form. Any outdated or incomplete information can delay the recredentialing process. It is crucial to keep all details current and accurate.
Forgetting to list the healthcare related organization(s) to which the application is being submitted. This information guides where the completed application should be sent and must not be overlooked.
Including unnecessary or incorrect attachments. Only attach the documents requested by the recredentialing application instructions. Adding extra, unrequested documents can cause confusion.
By avoiding these mistakes, practitioners can ensure their application is processed efficiently, paving the way for their continued practice without unnecessary delays.
The process of completing the Oregon Practitioner Recredentialing Application is comprehensive and requires the submission of several key documents and forms alongside it. These additional documents play a crucial role in verifying a practitioner's qualifications and ensuring they meet the standards needed to provide healthcare services. Here is a brief description of four other forms and documents often used together with the Oregon Practitioner Application form:
In addition to these documents, applicants may be asked to provide more specific forms based on their specialty or the requirements of the health care organization to which they are applying. Properly completing and submitting these forms and documents, alongside the Oregon Practitioner Recredentialing Application, ensures a smooth credentialing process, ultimately benefiting both the practitioner and the patients they serve.
The Oregon Practitioner Recredentialing Application shares similarities with the Initial Medical Staff Application forms used by hospitals and medical facilities for practitioners seeking to join their medical staff. These forms collect detailed information about a practitioner's education, licensure, board certifications, and practice history to assess their qualifications and abilities to provide care. Both applications require comprehensive personal and professional information, intended to ensure that the applicants meet the high standards necessary for providing healthcare services.
Like the DEA (Drug Enforcement Administration) Registration Application, the Oregon form requires specific licensing information, such as DEA certificates for practitioners who will prescribe medications. Both forms serve regulatory purposes, ensuring practitioners are authorized to perform certain duties within their scope of practice, including the handling of controlled substances, thus maintaining patient safety and adherence to federal regulations.
State Professional License Renewal applications are also akin to the Oregon Practitioner Recredentialing Application in that they necessitate up-to-date information on a practitioner's qualifications, disciplinary actions, if any, and current practice status. Both types of applications ensure that the practitioner is competent and fit to continue providing healthcare services, aligning with public safety and professional standards.
Continuing Medical Education (CME) Reporting Forms resemble the section of the Oregon application that documents ongoing education. Practitioners are required to report their completion of CME credits, demonstrating their commitment to maintaining and enhancing their clinical knowledge and skills, ensuring they remain abreast of the latest advancements and standards in medical care.
The Professional Liability Insurance Application process parallels parts of the Oregon application that address professional liability insurance details, including coverage and any past or pending claims. Both types of documents assess a practitioner's risk management through their insurance coverage, which is crucial for protecting both the practitioner and the patients in the event of malpractice allegations.
Board Certification and Recertification Applications share the aim of documenting the practitioner's specialty qualifications with the Oregon form. In both instances, practitioners provide evidence of their expertise and competence in specific areas of medicine, which is vital for credentialing processes and ensuring high-quality care in those specialties.
Healthcare Facility Credentialing Application forms, used by various healthcare organizations besides hospitals, such as ambulatory surgical centers or long-term care facilities, are similar because they comprehensively evaluate a practitioner's credentials, work history, and qualifications to ensure patient safety and high-quality care standards are upheld.
The Application for Clinical Privileges is another document that requires detailed professional information, similar to the Oregon Practitioner Recredentialing Application. Practitioners must list their desired clinical privileges and provide supporting documentation of their competence and experience in those areas, ensuring they are qualified to perform specific procedures and tasks at a healthcare facility.
Background Check Authorization forms, while generally shorter, are akin to aspects of the Oregon application that require disclosure of personal information for the purpose of conducting background checks. These checks help to verify the practitioner's identity, educational background, licensure status, and any history of disciplinary actions, ensuring patient safety and trust in healthcare providers.
Finally, the National Provider Identifier (NPI) Application process, which assigns a unique identification number to healthcare providers in the United States, shares the requirement with the Oregon form for providing detailed personal and professional information to secure a unique identifier. This number is essential for billing, identification, and efficiency within the healthcare system, further integrating the practitioner’s credentials into the national healthcare landscape.
When filling out the Oregon Practitioner Application form, paying attention to detail and following specific guidelines can make a significant difference. Here is a list of things you should and shouldn't do to help guide you through this process:
By following these do’s and don’ts, you can streamline the process of completing the Oregon Practitioner Recredentialing Application. This attentiveness not only helps in avoiding common pitfalls but also ensures that the application accurately reflects your qualifications and intent.
When it comes to the Oregon Practitioner Recredentialing Application, there are plenty of misunderstandings floating around. Here's a straightforward list to help clear up some of the most common misconceptions:
It's okay to modify the application's wording or format. This is a big no-no. Changing the wording or format can invalidate the entire application. It needs to be filled out as provided.
You can substitute a curriculum vitae for the application. While including a CV might seem helpful, it's not an acceptable substitute for the application itself. Every section of the application needs to be completed as instructed.
Only medical doctors need to apply. This isn't just for MDs. Any practitioner needing credentialing or recredentialing within Oregon should use this form. It’s important for a wide range of healthcare professionals.
You can leave sections blank if they don't apply. Actually, if a section doesn’t apply to you, there's usually a box to check off to indicate that. Leaving sections blank without explanation can lead to unnecessary confusion or delays.
The application doesn't need to be current. The application requires that all information be current, complete, and accurate at the time of submission. This includes ensuring all attached documents are up-to-date as well.
Signatures are optional. Signatures are mandatory on page 8 (Attestation Questions) and page 9 (Authorization and Release of Information Form), including Attachment A if it's applicable. Unsigned forms will not be processed.
You should send the completed application directly to the State of Oregon. The instructions specify that the completed application should be returned to the healthcare-related organization you're applying to, not to the State of Oregon.
Initialing every page is unnecessary. Each page of the application requires the applicant's initials and the date it was last reviewed. This is a necessary step to ensure all information is verified and up-to-date.
You can use any color ink to fill out the form. The application should be filled out in black or blue ink or typed using a different font than the form. This helps maintain clarity and legibility.
Emailing the application is preferred. While digital convenience is on the rise, the form specifically instructs to mail the application to the requesting organization(s). Adhering to the application instructions is crucial for proper processing.
Understanding and following the guidelines provided in the Oregon Practitioner Recredentialing Application is key to a smooth credentialing and recredentialing process. Keeping these common misconceptions in mind can help avoid mistakes and ensure your application is processed efficiently.
Filling out and using the Oregon Practitioner Recredentialing Application requires careful attention to detail and adherence to the guidelines provided by the Advisory Committee on Physician Credentialing Information (ACPCI). Understanding the purpose and following the instructions meticulously is crucial for the successful submission of the application. Here are four key takeaways for anyone preparing to fill out and submit this application:
In summary, the Oregon Practitioner Recredentialing Application is a thorough document that requires careful attention to instructions, complete and current information, and proper documentation. By following these key takeaways, practitioners can navigate the application process more effectively and ensure their submission is successful.
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